Sober Living Application – Healing Rock Homes

Resident Information
Full Name: Client first name Client last name
Date of Birth: Client birthdate
Phone Number: Client phone
Email Address:Client email
Current Address: Client Address Client City Client State Client Zip
Emergency Contact Name & Number: Text field Text field
Relationship:Text field

Recovery Background
Date of Sobriety (Abstinence Start Date): Date
Are you currently enrolled in a treatment program?Checkboxes 

If yes, program name & level of care: Text field

If you are not currently enrolled in a treatment program are you planning on entering a PHP or IOP program at the same time as Healing Rock Homes? Checkboxes

If yes, program name & level of care: Text fieldText field

Have you previously lived in a sober living home? Checkboxes

If yes, where/when? SoberLivingHistory

Do you attend 12-step, SMART Recovery, or other mutual support meetings? Checkboxes

Preferred modality (optional): Text field

Substance Use History
Substances used (check all that apply):

 Client substances of choice

Date of last use:Date

Legal and Medical Information
Are you currently on probation or parole? Checkboxes Probation

If yes, supervising officer name & contact:Text fieldText field
Do you have any court requirements to reside in sober housing?Checkboxes
Do you have any diagnosed medical or mental health conditions? Checkboxes

If yes, explain briefly: Client diagnosis
Are you taking any prescribed medications? Checkboxes

If yes, list medications and prescriber:Medication

Personal Commitments
Are you willing to submit to drug and alcohol testing? Checkboxes
Are you willing to follow curfew and house rules? Checkboxes
Are you willing to engage in a recovery community (meetings, sponsorship, etc.)? Checkboxes

Financial Information

Recovery Residence Fees at Healing Rock Homes are $600 per month, or $150 per week.  Healing Rock Homes will attempt to connect those without the ability to pay with grant funding or other public funding to assist with fees, but cannot guarantee any financial resources will be available to offset sober living fees.

Do you have the ability to pay weekly or monthly residence fees? Checkboxes
Are you employed or seeking employment?Checkboxes

If employed, list current employer: EmploymentHistory

Optional Short Answer 
What are your recovery goals while living in sober housing?

Text field
Why do you believe you are a good fit for this recovery residence?

Text field

Applicant Acknowledgment
Checkboxes 

Signature: Signature Date: Date